Once upon a time in a place far, far away, I worked in a neurosurgery department. PAs and NPs were used pretty much as mini-residents. We’d see patients after arrival at the clinic, talk to them and do a focused exam, and then report to a surgeon. At that point the surgeon would go back into the room with the PA, ask the patient a few unintelligible questions, offer the patient options that the patients completely didn’t understand, and then bark a few orders to the PA over their shoulder on their way out. And that was that.

Frequently, the orders would relate to pain care. This clinic had a very strict stance on pain medication. Even for patients who had undergone extensive brain surgery—including partial skull removal and related intracranial mayhem—little pain medication was given upon discharge. When patients would return in pain after using their brief run of short-acting opioids, the PA would be told to “send them to the pain clinic!”

Although I never had the will to ask this of my supervising MD, my internal response was “exactly which pain clinic are your referring to?” In my setting, like in most, pain clinics where patients like this could receive pain medication most commonly do not exist. It is rare for a pain clinic to take on prescribing pain medication after surgery at the request of the surgical team.

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Certainly this service should exist, but it almost always never does. So the PA in the clinic would try to reach out and ask the primary care provider to take on the medication tapering, and would usually be met with “Let me get this straight, PA Anderson. Your team just performed invasive and complicated brain surgery and now you want to dump the pain issue on me?”

This was one of many services that are needed, but don’t exist. It doesn’t take much time practicing as a PA to run into such non-existent services, exposing some of the giant gaps in care in our often crazy and poorly designed healthcare system. 

Another sorely needed but seldom available service is a resource to help patients taper benzodiazepines for those who want to stop taking this troublesome medication. I now work in an opioid treatment program (OTP, aka methadone clinic), working with patients attempting to stop their heroin or other aberrant opioid use by taking methadone or buprenorphine instead.  As anyone who has worked in an OTP knows, benzodiazepines can be the bane of OTPs and their patients. Benzodiazepines and opioids are always a potentially dangerous mix, which is why there is now a black box warning regarding prescribing benzodiazepines for patients taking opioids.

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Most of the patients I work with who take benzodiazepines struggle with success in treatment, and many of them desperately want to stop taking them. One of the difficulties of taking benzodiazepines is that it can be difficult to stop. Patients can become very sick in benzodiazepine withdrawal, with an increased risk of having seizures. I’ve known many patients who have had terrible things happen to them when trying to stop taking them, including seizures, nasty falls, and accompanying trauma, including fractures and facial injuries.

One of the problems is that patients who often start with a nonchalant benzodiazepine prescription end up having the prescription terminated and then they start taking them on the street, which makes it tougher to taper. OTPs don’t want to take it on the tapering process, because that would entail prescribing benzodiazepines. Primary care providers and psychiatrists are seldom willing to take on such a taper for the same reason. Yet there is little evidence-based guidance about how to taper people from these medications.

I know there are many more unmet needs for our patients. It can really make caring for complex patients difficult. I’d love to hear from you about what services are needed, but not available, in your settings. Drop me an email at [email protected].

Jim Anderson, MPAS, PA-C, DFAAPA, is a physician assistant in Seattle.